Arch Dis Child: first published as 10.1136/adc.61.2.198 on 1 February 1986. Downloaded from

Archives of Disease in Childhood, 1986, 61, 198-204

Contemporary history Child in : past, present, and future*

O RANSOME-KUTI College of Medicine, University of Lagost

I looked at the list of former Windermere lecturers The historian of the Nigerian health services, and realised the great honour conferred on me by Ralph Schram, comments: 'Lugard undoubtedly felt being invited to give this lecture. It is also a tribute that the advances were wonderful, but for 9-5 to the vigour of Nigerian paediatrics and paediatri- million Africans in Nigeria, the day of excellent cians, whose frustrations and achievements form the hospitals and improvements in sanitation were still major part of this lecture, and to those paediatri- far off.'1 cians, mostly your members, who set us on our Dr I L Oluwole began the first school health path-Dick Jelliffe, the late Bob Collis, Arthur services in in 1925, and maternal and child Tompkins, Ralph Hendrickse, David Morley, Hugh welfare services were established in the rural areas, Jolly, the late Bruno Ganz, the late Richard Dobbs, mostly by missionaries, around 1926. One of the and Bob Prosser, to name a few-and to those of earliest was in Ilesha, where, many years later, you in this country who have inspired, taught, and Professor David Morley carried out his historic supported us in our gigantic struggle to improve the studies. In the 1920s it was noted that deliveriescopyright. health of our children. often took place on the mud floor. The rooms were Before the arrival of paediatrics in Nigeria in dark, smokey, and overcrowded. The deliveries 1952, children were given scant attention. The were supervised largely by grandmothers, who often earliest health services were provided for sailors and introduced puerperal sepsis. The babies were left slaves. took a heavy toll of the lives of unattended until the third stage of labour, with explorers and missionaries who ventured inland, but oozing cords open to infection from tetanus, a risk and dedicated to increased the cord with cow the latter were the most persistent only by dressing dung. http://adc.bmj.com/ providing services for the indigenes. The govern- In 1930 consciences were stirred in Britain about ment services were developed mainly to care for the health of mothers and children in Nigeria, and European civil servants and army personnel and Dr Mary Blacklock was sent out by the Leverhulme were also preoccupied with eradicating malaria and Research Foundation to investigate 'certain aspects improving sanitation. From 1900 onwards small of the welfare of women and children in the hospitals and dispensaries were in evidence in towns colonies', but little action was taken. In 1931 a with no medical missionary establishments. By 1925 report on health in colonial Africa stated that 'the

Lord Lugard wrote: main factors which led to high infant and general on September 23, 2021 by guest. Protected 'The diseases of tropical Africa are comparatively few; mortalities are lack of sanitation, widespread inci- blackwater fever, malaria, dysentry and anaemia are the dence of debilitating diseases such as malaria, principal ones. Lung diseases, enteritis and cholera are helminth infections, schistosomiasis, and venereal rare or uncommon among Europeans. We have now, in diseases, lack of medical care, and dietetic deficien- the African Tropics, a most efficient medical service, and cies'. It is still so with a few more additions to generally speaking, excellent hospitals with an adequate today, nursing staff. To the skill of the doctors and the improve- the list. ments they have effected in sanitation etc, it is due that the Collecting of vital statistics became compulsory in returns of deaths and invalidings now show such a Lagos in 1863. More than a century later, however, wonderful decrease." important statistical data were rare, and the little information that existed was not properly used. For example, in 1952, Dr S L Adesuyi, a medical *Windermere Lecture, 1984, given at the 56th Annual Mccting of stressed the of hos- the British Paediatric Association. statistician, stupidity providing tSince giving this lecture Professor Ransome-Kuti has been pital beds almost exclusively for adults (90%) when appointed Minister for Health in Nigeria. children needed 40-50%. Moreover, the provision 198 Arch Dis Child: first published as 10.1136/adc.61.2.198 on 1 February 1986. Downloaded from

Child health in Nigeria: past, present, and future 199 of beds for women was only 20% when about half of In 1981, in the rural areas of Bendel State, the patients were women. Akenzua found eight traditional midwives per 1000 for Lagos was stated to be 450 per .5 Among other responses he received 1000 in 1900.1 Fifty years later it fell to 86 per 1000 from these midwives, 56% did not think it was and in 1973 it was reported at 70 per 1000 and 44-7 necessary to wash their hands and 36% the per 1000 by the United Nations Demographic Year perineum before delivery, and 20% would manage Book and the Federal Office of Statistics (Lagos), cases such as transverse lie and prolapsed cord and respectively. Because of the tremendous growth of 92% breech deliveries on their own. They are often the medical services and the prosperity of the people known to fail. Asked about the methods used to there has been a steady decline in infant mortality in resuscitate a baby who fails to cry at birth, the Lagos and perhaps throughout the Federation; answers varied from 'sprinkle alligator pepper on however, the method of reporting and collecting baby' (60%), to 'plug the anus with finger and pour data is such that the vital statistics for the nation are cold water on baby' (8%), and 'Nothing! It's God's still unreliable. wish' (4%). All of them were willing, however, to be More reliable data are available from surveys. trained in modern ways of midwifery and practice to The Rural Demographic Sample surveys carried out improve the quality of their service, and they are in 1965-6 give the country's infant mortality as 178 therefore a potential source of health manpower in per 1000, that of Lagos as 143 per 1000, and that of the rural areas. the former Western region and the former Federal In a provincial hospital in Ondo with no paediatric Territory as 79 per 1000. The surveys also reported a unit, intrapartum asphyxia due to prolonged child mortality (0-5 years) of 322 for boys and 306 labour was the commonest cause of the high for girls in rural Nigeria. Using age specific mor- perinatal mortality. Other causes were prematurity, tality, 40% of 1000 children born at year 0 will have twinning (16X4%), and congenital malformations. In died by the age of 5, most of these deaths occurring the University College Hospital, Ibadan, the causes in the first year. Data from our paediatric emerg- of high perinatal mortality were twinning (10% of all ency room at Lagos University Teaching Hospital pregnancies and also an important cause of pre- copyright. also indicated that infants (0-1 year) have the maturity), malpresentation, toxaemia, and the highest mortality among children admitted. tendency of women in Ibadan to have large With the opening of the first medical school in families.3 The women admitted to the hospital in Ibadan in 1948, paediatrics arrived in the country in Obadan were highly selective, and that hospital also the early 1950s. Health problems began to be had an excellent paediatric unit. defined mainly as they presented in hospitals, and Eighty per cent of babies are delivered in an solutions were found where it was possible. There unhealthy environment by unskilled attendants. In were, however, few community studies. hospitals or health centres they are discharged into http://adc.bmj.com/ At that time, the ratio of doctors to population the same contaminated environment within 48 was stated as 1:40 000. The desirable ratio for a hours. Ill babies pour from the community into country in the African region according to the hospital wards where facilities are most inadequate. World Health Organisation was 1:10 000. Nigeria In Lagos in 1981, 35% of newborn babies admitted was determined to achieve that ratio as soon as from the community were infected, 31-5% were possible in the hope that would thus be preterm, and 19-5% jaundiced. Moreover, 1021 available to all. It did so in 1980, by which time 13 jaundiced babies were treated as outpatients, 677 of on September 23, 2021 by guest. Protected medical schools were functioning. The health of our whom received exchange transfusions. Similar ex- children, however, has hardly improved. periences have been reported from Ibadan and other centres. Neonates Five conditions account for 76% of neonatal deaths in hospital-jaundice, infection, congenital The high perinatal mortality attests to the poor malformations, tetanus, and low birth weight quality of our obstetric care-45-6 per 1000 in (ranging from 21-3% in the North6 to 7-3% in Lagos,2 60-7 per 1000 in Ibadan,3 and 52 3 per 1000 Lagos,7 for babies born in hospital). Infections, in Ife.4 These hospital data (except the data for including tetanus, are the major causes of death. Lagos, which are for the whole city) include the Except for congenital malformations, all the outcome of deliveries attended in the early stages by conditions stem from factors in the environment. traditional midwives and brought to hospital when Neonatal jaundice is more severe in babies they go wrong. In Lagos 38% of deliveries were admitted from the community than in those born in assisted by traditional healers, or took place at thehospital, andglucose-6-phosphate dehydrogenase home. deficiency is the commonest cause among the Arch Dis Child: first published as 10.1136/adc.61.2.198 on 1 February 1986. Downloaded from

200 Rcnsome-Kuti former group. In 1967-8, 52% of children registered said that it gave the baby 'health and strength', in our neurological clinic had cerebral palsy due to concepts popular in Nigerian culture and often used neonatal jaundice. In Lagos mothers of babies in food advertising." admitted for jaundice stated that they had used Many mothers also stated that breast milk was not mentholated dusting powder on the umbilical cord. sufficient. Early bottle feeding is known, however, A controlled trial in infants deficient in glucose-6- to lead to a possible failure to empty the breast, phosphate dehydrogenase who had been born in resulting in a dampening of the 'let down' reflex and hospital indicated that those who had had the reduced breast milk output. The need for bottle powder applied to the umbilical cord developed feeding is thereby increased and ultimately super- jaundice more often and more severely.8 venes. When, because of ignorance or , In 1983 it was reported that herbalists were dilute formula feeds are thereafter given to the familiar with jaundice in the newborn and believed baby, marasmus develops. it to be transferred from the mother (and occasion- Added to bottle feeding, the highly contaminated ally from the father) to the fetus or caused by environment, poor personal hygiene, ignorance, shortage of blood in the newborn, fever, and the dearth of a potable water supply also bites, blood spilling into the eyes of the baby at account for the high incidence of gastroenteritis. birth, bad water in the baby's body, and the mother Oral rehydration therapy is gaining ground rap- eating bananas during pregnancy.9 They would treat idly and saving many lives. Its use was taught to it by administering concoctions of herbal medicine mothers in our primary health care service in Lagos. or washing the baby with black soap. After fours years a community survey indicated that 61% of 247 registered mothers knew the correct Older children formula but only 32% of these had used the solution during their child's last episode of diarrhoea, which The emergency room, where only very ill children showed a reluctance of mothers to take responsi- are admitted, is the busiest unit in academic bility for the care of a condition which, in their paediatric departments. It is the point of entry from experience, could-lead to death. At the same time,copyright. the community into the outpatient department and the dread of a depressed fontanelle is clearly shown for 80% of admissions into the wards. It mirrors the by potions and pastes applied to it, but which is not health problems in the community and provides an associated with loss of fluid and the need to replace indication that the community health support sys- it. More efforts are needed at community level to tems have failed. promote the use of oral rehydration solution by Most conditions seen in the emergency room are mothers. preventable or easily cured if diagnosed and treated Most children are weaned on maize gruel. This early. But these diseases are not 'interesting' to the inappropriate feeding practice at the weaning http://adc.bmj.com/ 'tertiary' trained and situated physician until they period, whereby culture or ignorance dictates that occur in their worst form. The worst hit are children predominantly carbohydrate diets are fed to the aged 2 years and below. These children constituted infant, is a major cause of diarrhoea and malnutri- 94% of all admissions to the emergency room in tion. This is in spite of the fact that there are staple Ibadan in 1968 and a similar proportion of deaths in food items in the community suitable for weaning Lagos. The situation remains the same in 1984. infants successfully. Ilesha In the mothers of malnourished children on September 23, 2021 by guest. Protected Gastroenteritis and knew of the disease protein energy malnutrition, 64% calling it 'kosoko' (no hope) or 'orinla' (big Nigeria is suffering the decline in breast feeding head).'2 They believed that the child had 'super- reported from various parts of the world. In Lagos natural powers' to die and be reborn. They also in 1968 dietary histories of patients with malnutri- believed that the disease was communicable. None tion indicated that bottle feeding was added to mentioned an inadequate diet as the cause.12 breast feeding by all mothers during the babies' first Children with malnutrition seen in hospital are month of life.'0 In Ibadan in 1973 a report to the the tip of the iceberg, with a large reservoir of United Kingdom Committee of the Freedom from potential cases ready to be struck down by measles, Hunger Campaign showed that bottle feeding was , whooping cough, and diarrhoea. It is started at less than 1 month of age by 52% of necessary, therefore, to restore the mother's confi- mothers, and 94% introduced bottle feeding by the dence in breast feeding and instil into her relevant age 2-3 months. In Lagos most mothers of mal- and effective weaning practices, otherwise our nourished children surveyed bottle fed their babies present knowledge about infant feeding will have because they 'took a fancy' to it. In Ibadan mothers been acquired in vain. Arch Dis Child: first published as 10.1136/adc.61.2.198 on 1 February 1986. Downloaded from

Child health in Nigeria: past, present, and future 201 Malaria/convulsions administered for any episode of fever.16 With this regimen, the number of febrile convulsions in the In the clinics malaria presents as fever. It is the children in the community was considerably re- commonest complaint, most frequent and severe in duced, presumably due to the prevention of those children aged between 9 and 24 months. By age 5 caused by malaria. At the same time, the children years the clinical manifestations of malaria are less were given an opportunity of developing immunity severe, and the child has acquired considerable to malaria. immunity. It is therefore rare for malaria to be the cause of death in this holoendemic area in older and Measles school children, but the infection does give rise to a high prevalence of morbidity.13 Of all the infectious diseases amenable to preven- This pattern, however, is changing due to the tion through immunisation, measles is the most widespread use of antimalarial drugs. For example, devastating. A high level of coverage with its in the rural clinic established by David Morley in vaccine is difficult to achieve because of expense and Imesi-Ile, where the children were given pyrimetha- fragility. Although measles immunisation is recom- mine prophylaxis, parasite rates were lower in mended at the age of 9 months, in Lagos, for patients in the treated than in the untreated example, it is estimated that 30% or more of village.'4 measles cases occur before that age, and vaccination The most severe forms of malaria are seen in at 6 months has often been ineffective. The fact that hospitals. One form presents with high fever and the child develops measles after immunisation prolonged convulsions. It is also common in children erodes the mother's confidence in the vaccine and aged between 9 months and 3 years. Thirty to 40% brings it into disrepute. In the Cameroons, workers of the children die within 72 hours of admission. from the Center for Diseases Control, Atlanta, Malaria parasites can be shown in the blood film of a Georgia, have documented a drop in the incidence third of the patients. The disease is dreaded by the of measles in the 0-8 months age group from 88-2 parents, who believe that when the children clench per 1000 to 31-8 per 1000, with a vaccination copyright. their teeth death is imminent. To prevent this coverage of 40% in 9 month old infants. 17 They also disaster, the child's mouth is severely traumatised in expect that higher rates of coverage in the 9- 23 year the attempt to keep it open. In one case, a father age group will further reduce its incidence in the squeezed the buccal pad of fat into the child's mouth under 9 month age group. by exerting pressure on both sides of the cheek. From the evidence available in Nigeria, the Shock treatment is also applied, such as burning of performance of our Expanded Immunisation Prog- the feet or buttocks or rubbing pepper into the eyes. ramme since 1976 has been dismal. Evaluation in A mixture containing mainly cow's urine, tobacco the Oranmiyan Local Government Area of Oyo http://adc.bmj.com/ leaves, and various herbs, shown to cause hypogly- State found very low levels of immunisation cover- caemia in rabbits, '5is given to many. This poison is age for diphtheria, pertussis, and tetanus, a major contributor in about 60% of the deaths due vaccine, and measles vaccine between 1977 and to this condition. 1981.18 The reasons for the poor performance were We surveyed mothers in the community regarding identified as: the use of cow's urine mixture; 27% gave it to their (a) inadequate community participation in the children regularly once, twice, or more daily, on its planning and implementation of the pro- on September 23, 2021 by guest. Protected own or mixed with herbs or other medicines, and, in gramme; most cases, the child always improved. The mixture (b) poor communication between different gov- is given routinely to prevent convulsion, and so ernment representatives; and when the child convulses, a large amount is poured (c) inadequate publicity. down his throat. This is the community's perceptionv Moreover, vehicles were grounded for most of the of a drug now known to be poisonous. Its use is year and frequent power failure caused wastage of considerably reduced in the urban areas but con- large quantities of vaccines, which cast doubt on the tinues in the villages. potency of those administered to the children. An ideal regimen for malaria would be one by In 1984 it was reported that no child in Tafawa which the child could be partially protected so that Balewa Local Government Area, Bauchi State, and he did not develop a severe attack of malaria and at only 9% in Owo Local Government Area, Ondo the same time would still be capable of manufactur- State, were fully vaccinated after three years of the ing antibodies against the parasite. One such regi- programme. Irregularities in financing of the State men was described by Morley in 1971 in which and Federal Health Ministries led to erratic pur- pyrimethamine was given monthly and chloroquine chase and distribution of vaccines. A lack of Arch Dis Child: first published as 10.1136/adc.61.2.198 on 1 February 1986. 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202 Ransome-Kuti planning to involve the grassroot implementers and innovations in the delivery of child health services. inadequate training and poor supervision were also Because of the shortage of doctors at that time he found. None of the refrigerators at the local gov- transferred most of the responsibilities for treating ernment office and the two health clinics visited the early stages of the common diseases to nurses. were functioning because of power failure, nor was Since then, we have learned that even lesser trained the stand by generator working. Considerable health personnel, down to the level of the village amounts of vaccines were spoilt due to neglect in health worker, can be successfully trained to assume monitoring vaccine storage temperature and some of these responsibilities. potency. More than 94% of mothers did not know Morley integrated preventive and curative ser- why their children were being immunised and at vices; introduced the home based record system; the what age they should be immunised. 'road to health' chart; simple diagnostic tools such as In spite of these gross deficiencies, the imple- the arm circumference strips; and therapeutic skills mentation of this programme was revised in Owo such as the use of salt, sugar, and water solution to with the aid of UNICEF in 1983 and has resulted in prevent dehydration. Although he showed a reduc- a 38% coverage of children aged 1-2 years with tion in mortality and morbidity in the treated target immunisation in the first month of the villages using limited resources, the system rapidly reactivated programme and 58% by the fourth, deteriorated after his departure because there was indicating that with commitment, efficient organisa- no government and community participation.'4 Of tion, and management the immunisation state of our the two, the latter is the key to effective health children can be considerably improved. services. Community participation means that the Running through this discussion is a well known citizens control the process of transformation theme-that children in developing countries are so whereby they mobilise and act to improve the ill and die in such large numbers because of the quality of their lives. In this process existing social inimical environment in which they live. The structures or those created for the purpose, such as human, socioeconomic, cultural, and environmental village health or development committees, must be elements of the society, therefore, need to be the medium. Appropriate health technology must,copyright. transformed. Most of our people still believe in and as much as possible, be transferred to and used by utilise traditional medicine born out of superstition, the members of the community. On the other hand, spiritualism, and the worship of ancestors ingrained local technologies found to be effective should be in us during our evolution over centuries. Many of encouraged-for example, the Hausa cut the umbi- us who have acquired the skills of modern scientific lical cord with a red hot knife. For this reason, medicine were catapulted from a traditional past to tetanus is relatively uncommon in their newborns. this new era, perhaps in a generation. Just as when a At all times the aim is to develop the spirit of self pagan becomes a Christian, we tend to turn our reliance within the community and incorporate http://adc.bmj.com/ backs on the past, enshrined in the community, and patterns of scientific health care into the traditional look to the future-the life and medicine of the system. Properly motivated, the community will developed world-forgetting that even that had a take action in its own interests towards achieving traditional past and developed through a process of better health. research and application of its results. We have to go Mothers are our best ally in this enterprise. It is back to where our people are and evolve with them. the uneducated woman (and they are in the vast Most of our doctors, and particularly paediatri- majority) who bears the largest number of children cians, work in the pinnacle of the health care and loses the most, who fails to understand simple on September 23, 2021 by guest. Protected delivery system-the teaching hospitals-perpetually concepts such as the meaning of the growth chart, reaping the morbid harvest of the contaminated and who performs worst of all in bringing her child community. We do not possess the skills to work for immunisation even when the services are made with and transform the community to stem the tide available, affordable, and accessible and are effi- of ill children. ciently run. She is subjected to enormous social and Asuquo Antia, one of our distinguished paediatri- cultural constraints that prevent her from utilising cians, once sounded 'a note of caution to all those the services effectively and is also subjected to concerned with child health in the Tropics that all conflicting advice from ancient and modern health change is not progress and that increased sophistica- systems regarding the care of her child. In any case, tion does not necessarily mean advancement."'9 But the father's role in these health decisions is often the question to be asked is, 'What change do we dominant. Moreover, the mother is striving to need to ensure progress?' function in a modern economy with inadequate, David Morley in the early 1950s worked in inappropriate, or no educational preparation. Nigeria and was the first to see the need for It is difficult to convince mothers of the need and Arch Dis Child: first published as 10.1136/adc.61.2.198 on 1 February 1986. Downloaded from

Child health in Nigeria: past, present, and future 203 efficacy of preventive measures, hence elaborate This should be the function of the universities at this 'outreach' or community based systems must be set time. Of all the tasks (preventive, promotive, and up to induce her to use the services. For example, an curative) necessary to improve the health of the infant's first visit to a health facility is usually for an population, only curative ones are predominantly episode of illness, often occurring past the age of 6 emphasised and taught in medical schools. months when the first phase of immunisation should Doctors are acknowledged leaders in the health have been completed, and at a time when the child is care systems, and their opinions are sought and most vulnerable to preventable infectious diseases. respected by governments. To be effective as an There is evidence indicating that when adequate advocate for relevant services of the kind described spacing or a reduced number of children per family above, our doctors should be trained to head a is achieved their health improves. For example, as primary health care system and also to function as a the size of the family increases so the chances of house officer in a hospital on qualification. To malnutrition,20 low birthweight babies, gastroenter- accomplish this type of training, our medical schools itis, respiratory infections, and a lowering of intelli- should have a model primary health care practice gence quotients also increase. Arguably, if parents area in which to teach community care to a standard perceive that their children will survive due to of excellence, just as a teaching hospital is required efficient child care services they will take steps to to teach individual care. Fortunately, this need is reduce the size of their families. Evidence in support being recognised and accepted, and medical cur- of this hypothesis comes from Imesi-Ile, where it ricula are being revised to train doctors with the was found that the desire for additional births was relevant knowledge, attitude, and skills to tackle our less in the village with an efficient clinic for the health problems in our own setting. under 5s than in one without.21 The slogan is 'Health for all by the year 2000'. In Ebenbo village in Cross River State it was There never has been health for all, and never will concluded that the women compensate by having be, but we can make health care available and additional children almost exactly equal in number accessible to all by the year 2000. to the number of deaths they have had, and that if copyright. child mortality can be reduced, there might well be a corresponding decline in completed family size.22 References The smallest families are those of the highest social 1 Schram R. A history of Nigerian health services: Ibadan: Ibadan class, and they also have the lowest infant and child University Press, 1971. 2 Akesode FA. Registration of births and deaths in Lagos, mortality. Nigeria. J Trop Pediatr 1980;26:150-5. The challenge is to establish a health care system Nylander PPS. Perinatal mortality in Ibadan. Afr J Med Sci that will touch the lives of every member of the 1971 ;2:173-8. community, especially children, who are the most 4 Sogbanmu MO. Perinatal mortality and maternal mortality in http://adc.bmj.com/ general hospital, Ondo, Nigeria: use of high risk pregnancy vulnerable, and that will tackle those conditions predictive scoring index. Niger Med J 1979;9:123-7. causing the highest mortality and morbidity. The 5 Akenzua GI, Akpovi SU, Ogbeide 0. Maternal and child care system must be organised from the grassroots, in rural areas: the role of traditional birth attendants in Bendel integrating preventive, promotive, and curative state of Nigeria. J Trop Pediatr 1981;27:210-4. 6 Rehan NE, Tafida DS. Low birth weight in Hausa infants. services; using the type of technology that the Journal of Nigerian Pediatrics 1981;8:35-39. members of the community will accept, at a level 7 Fadahunsi 0. Low birth weight and maturity in the Nigerian infant. Niger Med J 1976;6:324-6. they can utilise, maintain, and afford, and with an on September 23, 2021 by guest. Protected efficient and effective system of supervision and Olowe SA, Ransome-Kuti 0. The risk of jaundice in glucose-6- phosphate dehydrogenase deficient babies exposed to menthol. referral. Acta Paediatr Scand 1980;69:341-5. A first step is to study the principles underlying 9 Oyebola DDO. Care of the neonate and management of the implementation of such a system in a traditional neonatal jaundice as practiced by Yoruba: traditional healers of setting. Without this we cannot reasonably expect to Nigeria. J Trop Pediatr 1983;29:18-22. 10 Ransome-Kuti 0, Gbajumo W, Olaniyan MO. Some socio- supplant a traditional health system that the people economic conditions pre-disposing to malnutrition in Lagos. have learnt to trust, that is serving them well, and Niger Med J 1972;2:11 l. whose language is understood and verdict accepted. " Orwell S, Murray J. Infant feeding and health in Ibadan. J Trop Traditional medicine demands compliance through Pediatr 1974;21:212-3. 12 Ojofeitimi EO. Causes of protein energy malnutrition as viewed dogma, communal pressure, and faith; scientific by the clients' mother. J Trop Pediatr 1982;28:147-8. medicine demands reasons and proof, attributes 13 Fasan PO. Malaria in the school children of Lagos city and acquired through modern . Lagos state. West African Medical Journal 1969;18:176. National programmes require political will and 14 Cunningham N. The under fives clinic. What difference does it make? J Trop Pediatr 1978;24:239-334. social and economic reforms. But, while waiting for 5 Grange A. Experimental studies on cow's urine mixture. these, the health technology should be put in place. American Tropical Pediatrics 1981;1:175-9. Arch Dis Child: first published as 10.1136/adc.61.2.198 on 1 February 1986. Downloaded from

204 Ransome-Kuti

16 Morley D. Malaria in childhood. Trop Doct 1971;1:159. growth and nutritional status of infants and young children in a 17 Heymann DL, Maben GK, Murphy KR, Guyer B, Foster SO. Nigerian village. Trans R Soc Trop Med Hyg 1968;63:164. Measles control in Yaounde: justification of one dose nine 21 Cunningham N. Report to the US Aid Conference on the use of month minimum age vaccination policy in tropical Africa. weight charts. Washington: 1971. Atlanta: International Health Programme Office, Centers for 22 Mott FL. The dynamics of demographic change in a Nigerian Disease Control, 1984. village. Monograph no 2, Human Resource Unit. Nigeria: 18 Jinadu MK. A case study in the administration of EPI in University of Lagos, 1974. Nigeria. (Perspectives in primary care). J Trop Pediatr 1983;29:217-9. Correspondence to Professor 0 Ransome-Kuti, Professor of 19 Paediatrics and Primary Care, College of Medicine, University of Antia AU. Progress, in child health. Nigerian Journal of Lagos, P M B 1001, Surulere, Lagos, Nigeria. Pediatrics 1976;3:37-8. 20 Morley DC, Bicknell J, Woodland N. Factors influencing the Received 18 November 1985 copyright. http://adc.bmj.com/ on September 23, 2021 by guest. Protected